HospitalInspections.org

Based on observation, interview, and records and policy and procedure review, the facility failed to ensure that it had, for two ( #1 and #3) of three sampled patients, the immediate availability of nursing staff for appropriate interventions and dependent assistance to the bathroom.


The findings include:


1.) A telephone interview was conducted with the daughter of Patient #1 on 11/04/2019 at 2:13 PM. She confirmed that Patient #1 needed assistance to use the bathroom because Patient #1 was admitted to the facility as a result of a fall at home. The daughter also stated that while at the beside of Patient #1 on September 30, 2019, the facility staff did not respond to the call light for 30 - 40 minutes when activated. The daughter stated that she had to go out into the hallway to get assistance for Patient #1. The daughter of Patient #1 stated that facility staff called her at 2:10 AM on 10/01/2019 and reported that Patient #1 fell while going to the bathroom. The daughter stated Patient #1 reported to her that staff would not come and help Patient #1 to the bathroom. The daughter also stated that nursing staff failed to ensure that the bed alarm was on.


During an interview with Employee C, Registered Nurse (RN) on 11/08/2019 at 1:26 PM, it was confirmed that the bed alarm was not activated for Patient #1.


An interview was conducted with the Employee E, RN Unit Manager on 11/08/2019 at 2:39 PM. She confirmed that the nurse who cared for Patient #1 when Patient #1 fell, did not turn the bed alarm on. Employee E, RN also confirmed that the staff member, Employee F, RN documented that the bed alarm was not on when Employee F, RN completed documentation for Patient #1. Employee F, RN was not available for interview.


A review of the documentation report which involved Patient #1 included a fall on 10/01/2019. It was documented that staff contacted the daughter of Patient #1 at 2:10 AM on 10/01/2019 and confirmed that the bed alarm for Patient #1 was not on at the time. A review of the fall risk assessment for Patient #1 revealed that Patient #1 had a Morse Fall Risk Score greater than 45 and had a fall at home.


A review of the facility policy "Adult Falls Prevention and Management" was conducted. It documented the purpose, "Establish comprehensive standards of care for the initiation of appropriate safety measures and interventions." Protocol 9 documented additional safety interventions for high risk is required to be implemented at bedside and documentation in the flow sheet included "Bed/chair alarm on." This was a documented Nursing intervention.


2.) An interview was conducted with Patient #3 on 11/08/2019 at 7:56 AM. Patient #3 stated that last night 11/7/19, staff did not respond to her for over two hours when she activated the call light to go to the bathroom. As a result of staff not responding to her call for help, she stated that she soiled herself. When asked, she stated she had a bowel movement in bed.


An interview was conducted with Employee A, RN on 11/08/2019 at 8:10 AM. She confirmed that she had "heard" that Patient #3 had called since 4:30 AM and she had soiled herself. Employee A, RN verified that Patient #3 was alert and oriented to person, place and time and Employee A, RN did not know why Patient #3 did not get up and go to the bathroom. Employee A, RN confirmed that she and Employee B, RN went into the room of Patient #3 at about 6:30 AM during shift change and found Patient #3 in stool.


An interview was conducted with Employee B, RN (Charge Nurse) on 11/08/2019 at 8:30 AM. She confirmed that Patient #3 told her that they called for help around 4:30 AM and that Patient #3 had been waiting until approximately 7:00 AM. Employee B, RN confirmed that Patient #3 was found in stool and was told by Patient #3 that she had been waiting since 4:30 AM.


A review of the "Morse Fall Risk Score" for Patient #3 was conducted with Employee C, RN and it was confirmed that Patient #3 did not have a score below 45, which indicated that Patient #3 was at a high risk for falls.


A review of the facility-provided Call Detail Log for Patient #3 documented the following confirmed calls for nursing assistance: Patient #3 in Room 5012 called on 11/08/2019 at 4:39 AM; Patient #3 called on 11/08/2019 at 4:41:34 AM; Patient #3 called on 11/08/2019 at 4:48: 35 AM, answered in 5 seconds. The next recorded call made by Patient #3 and was responded to by Employee B, RN and Employee A, RN which occurred on 11/08/2019 at 6:48:53 AM, answered in 6 seconds. This was the reported time that Patient #3 was found in stool from the 4:48 AM last call captured on the call audit.


An interview was conducted with the Employee B, RN on 11/08/2019 at 8:30 AM and Employee A, RN confirmed that when the concern reported by Patient #3 was reviewed, Employee B, RN stated that when the Nurses' Aide looked at her pager device to see whom the call was sent to, she stated, "She missed the call." Employee D, Patient Care Technician (PCT) interview was attempted, but Employee D, was unavailable to confirm what prevented Employee D, PCT from responding to the 4:48 AM call made by Patient #3.


An interview was conducted with Employee E, RN Unit Manager on 11/08/2019 at 2:39 PM. She confirmed that if Patient #3 was a high risk for falls, then she should have had a bed alarm activated. She provided that the initial assessment placed her at a score of 70 (High Risk for Falls) and on 11/07/2019 at 45, which indicated a high risk for falls.


A review of the facility policy "Adult Falls Prevention and Management" was conducted. It documented the purpose, "Establish comprehensive standards of care for the initiation of appropriate safety measures and interventions." Protocol 9 documented additional safety interventions for high risk are required to be implemented at bedside and documentation in the flow sheet included, "Bed/chair Alarm on" and "Implement Toileting program with rounding (to help avoid patient getting up without assistance)."